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Glossary

Dislocations

While dislocations and ligament injuries are common throughout the hand,
they are most common at the proximal interphalangeal (PIP) joint.
The spectrum of these injuries ranges from minor stretching (sprains) to
complete disruptions of the ligaments.

Ligament injuries

The collateral ligament usually tears at one of two locations:
a) at its attachment to the proximal phalanx
b) at its attachment to the volar plate and middle phalanx.
Often, these injuries are accompanied by a partial lesion of the volar
plate.

Accompanying fractures

Avulsion fractures

Avulsion fractures are the result of side-to-side (coronal) forces acting on
the finger, putting the collateral ligament under sudden tension. The ligament
is usually stronger than the bone, causing the ligament to avulse a fragment of
bone at its insertion.
Avulsion fractures result in marked joint instability.
If the fracture is not displaced, nonoperative treatment is usually indicated
(buddy taping to the adjacent finger). Displaced fractures, however, must be
internally fixed.

Tension band principle

The tension band converts tensile forces into compression forces.
The presence of comminution is a contraindication for tension-band
treatment.
In a case such as the illustrated fracture, the tension band will be applied in
static mode.
Tension band wiring of this fracture has been shown to be effective and usually
provides good results. The advantage of this technique is its limited
soft-tissue disruption. The risk of fragmentation is also minimized.

Indirect reduction

Reduction is achieved by pulling the finger laterally, in the direction
opposite to the forces that created the fracture, and into MP flexion, as
necessary, to approximate the fragment. The avulsed fragment is pushed into
place by the surgeon’s thumb.

With tiny fragments, indirect reduction can be achieved by tightening the
tension-band wire at the end of the fixation procedure.

Direct reduction

In displaced fractures, open reduction is often necessary.
A dental pick is used gently to reduce the fracture from palmar to dorsal and
from proximal to distal. Application of excessive force can result in
fragmentation.

NoteAnatomical reduction is important to prevent chronic instability, or
posttraumatic degenerative joint disease.

Drill a hole

A hole is drilled in the middle phalanx, from dorsal to palmar.
The location of the drill hole should be the same distance from the fracture
line as the avulsed fragment’s length.
Use a drill guide, for soft-tissue protection, and either a slow-spinning 1.5
mm drill, or a 1 mm K-wire.

Insert wire

Thread a 0.6 mm stainless steel monofilament wire through the drill
hole.
A fine, curved hemostat can be used to retrieve the wire from the palmar
surface, sliding it very closely to the cortical bone in order to avoid damage
to the digital nerve and artery. Periosteal elevators can be used for
protection.

Wire application

The wire is passed through the drill hole and then around the fragment and
K-wire, through the ligament attachment, in a figure-of-eight mode.
This can be achieved by passing a syringe needle of appropriate diameter on the
surface of the bone, deep to the ligament attachment, and then inserting one
end of the wire into the tip of the needle. The needle and the wire are then
carefully drawn through, guiding the wire along the correct track.

Anchoring the K-wire

Check the position of the K-wire using image intensification. If the tip of
the wire is in contact with the far cortex, then retract the K-wire by about 2
mm, bend it through 180 degrees, cut the wire to form a small hook, and impact
the bent tip into the bone.

Tighten the wire

Once the fragment is reduced, the wire loop is tightened, cut short, and
bent along the phalanx, in order to avoid soft-tissue irritation.
When tightening the wire, ensure that both ends are twisted around each other
rather than twisting one end around the other straight end.